4 Surprising Causes of Balance Problems in Adults 50-Plus

These disorders could be the reason a person feels like they’re on shaky ground

Orly Avitzur, M.D.

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Published June 12, 2025

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Feeling dizzy or off-kilter? You’re not alone. Balance difficulties are one of the top reasons adults come to me as a general neurologist. And believe it or not, there’s not just one diagnosis that could explain those difficulties. Quite a few brain or nerve conditions can cause an older adult to feel unsteady, or worse, fall and end up in an emergency room.

“Good balance depends on three things working well together,” says neuro-otologist Terry D. Fife, M.D., director of the balance disorders and vestibular neurology program at Barrow Neurological Institute in Phoenix.

The three are: being able to feel where your joints and limbs are in space, coordinating information from your eyes and inner ears, and your muscles’ ability to carry out the brain’s instructions. If any of those systems go awry, you may feel unstable on your feet.

If the cause is not obvious, such as a new medication or an inner ear infection, then it’s time for a more thorough approach. “That means going to a neurologist to provide a good history of how the balance problem developed, undergoing a careful physical exam and sometimes having imaging or other tests,” Fife says.

I asked neurology colleagues to share how they diagnose four easy-to-miss disorders that throw off equilibrium in people over 50.

1. Normal pressure hydrocephalus

Billy Joel announced in late May that he was taking a break from performing because of normal pressure hydrocephalus, a disorder in which the fluid-filled spaces in the brain, called ventricles, are enlarged. He had fallen onstage in February and had surgery to address the problem.

NPH is more commonly seen in people 60 and older, but it’s rare, affecting about 800,000 older Americans. Trouble with balance and walking are the main symptoms, followed by difficulties with bladder control and cognitive struggles that mimic dementia.

“If we take a little stumble on the sidewalk, we correct ourselves. But patients with hydrocephalus don’t have those postural reflexes,” says Michael A. Williams, M.D., director of adult hydrocephalus and CSF disorders at the University of Washington. They can fall “just turning around in the kitchen; it’s as though their feet are stuck and over they go,” he says.

To test for NPH, Williams places the palm of his hand on a patient’s upper chest and asks them to resist as he gives them a slight push backward. If their postural reflexes aren’t working, they step backward to try to catch themselves or start to fall. If all is well, they can resist the push.

Testing for the disorder typically entails getting an MRI of the brain. If hydrocephalus is discovered, Williams assesses the response to the temporary removal of spinal fluid. If there is improvement, there’s a good chance the patient will benefit from a shunt to drain the excess fluid from the brain, Williams says, adding, “The happiest part of my job is when somebody comes back [after surgery] and says, ‘Look at me!’ and they don’t have a walker anymore.”

2. Orthostatic hypotension

Have you ever stood up quickly and lost balance or felt dizzy? That may be orthostatic hypotension, also called postural hypotension. It affects about 1 in 5 people over 60 and comes about with a quick blood pressure drop upon standing. It can be a side effect of certain medications given for high blood pressure, depression or pain. It can also occur in people who are dehydrated, severely anemic or out of shape.

“Orthostatic hypotension can also be due to damage in the nervous system, from areas of the brain that are affected by certain degenerative diseases, or from the nerves that go to blood vessels,” says Elizabeth A. Coon, M.D., a neurologist at the Mayo Clinic who specializes in autonomic and movement disorders. The autonomic part of the nervous system regulates processes we don’t really control, such as heart rate, blood pressure, respiration and digestion.

“In autonomic disorders, people who feel off-balance also may have other symptoms: sweating or tearing problems, a heart rate that doesn’t go up when it should — like with exercise or climbing stairs — and blood pressure that is too high or drops too much with standing,” Coon says. She asks patients if they have these complaints or any gastrointestinal, urinary or sexual problems that may accompany this group of disorders.

“If the examination confirms a fall in blood pressure, we may ask patients to undergo a tilt table test,” she says. The patient is safely strapped to a table that is moved into various positions while vital signs are monitored. Depending on the cause, a variety of treatments may be offered, such as increasing fluid or salt intake and wearing compression garments to improve blood flow.

3. Peripheral neuropathy

About 20 million people in the United States have some form of peripheral neuropathy. It is more common in older adults, affecting between 3 to 8 percent of people over 55. “There may be a hundred or more different causes of peripheral neuropathy, diabetes being the most common,” says Kerry H. Levin, M.D., chairman of the department of neurology at the Cleveland Clinic.

“When small nerve fibers are affected, it leads to sensory loss and discomfort — not sensing your feet well on the floor. And when large nerve fibers are involved, you have trouble knowing where your feet or joints are in space or may experience muscle weakness,” he says. “Any of these developments can lead to difficulty with balance.”

The risk for falls worsens when lights are low or you’re carrying things, Levin adds. “When you’re young and have very good joint position sense, you can navigate with little light. But when you have peripheral neuropathy, climbing stairs in poorly lit areas or with bundles in your hands, unable to see your feet, may cause you to have near falls or stumble," he says.

When he sees patients with neuropathy, Levin tries to find the cause of the condition. Correcting certain vitamin excesses or deficiencies can improve neuropathy, as can treatment of inflammation, he says. “Teaching people to maximize their safety through physical therapy or devices to aid balance or [address] ankle weakness can be very useful.”

4. Silent strokes

We hear a lot about transient ischemic attacks (TIAs), also known as ministrokes, which cause a temporary disruption of blood flow to the brain and short-lived symptoms. But they do not lead to lasting brain damage. A silent stroke, on the other hand, can cause brain damage without any obvious symptoms. Silent strokes affect 3 to 8 percent of people in their 50s, with rates rising to as high as 15 to 40 percent of people over 80.

Stroke prevention specialist Kevin Sheth, M.D., says it’s a paradox that strokes can be silent but still cause symptoms. “The difference is that oftentimes we think of non-silent or regular strokes as causing language problems or paralysis on one side of the body,” says Sheth, professor of neurology and neurosurgery at Yale School of Medicine. “But we may not appreciate the connection between strokes and … difficulty with balance or walking and attribute it to other causes,” he says.

“If you find yourself starting to hesitate on a flight of stairs, if you’re feeling a bit off-balance, or if you’re just a touch slower to initiate movements, all those tendencies may be very subtle symptoms of silent strokes,” he says.

The risk factors for silent strokes are the same as for all types of strokes, Sheth says. The main risk factors are high blood pressure, high cholesterol, lack of exercise, poor sleep, diet and smoking cigarettes. “If you are over the age of 50, you should bring up those issues proactively with your doctor,” says Sheth. Stress is another risk factor worth alleviating, he says, “whether it’s by engaging in tai chi, yoga, walking in nature or spending time with loved ones.”

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Orly Avitzur, M.D., the former president of the American Academy of Neurology, is a practicing neurologist in Tarrytown, New York, currently working on a medical memoir, A Very Good Brain. She is the former medical director at Consumer Reports and past editor-in-chief of Brain & Life magazine.